At Pediactric Surgery Update Course 2021, Dr. Bethany Slater from UChicago Comer Children's Hospital and Dr. Steven Rothenberg from Rocky Mountain Hospital for Children sharing their cases on using magnet therapy as an alternative treatment option for esophageal atresia.
100:00:00,133 --> 00:00:04,070If you missed our stay current pediatric surgery update course,
200:00:04,771 --> 00:00:07,540don't worry, because we're going to summarize
300:00:07,540 --> 00:00:10,510our favorite sessions right here on this podcast.
400:00:10,977 --> 00:00:13,880In today's episode, it's all about esophageal atresia.
500:00:14,180 --> 00:00:15,448We've talked on this podcast
600:00:15,448 --> 00:00:18,151about various surgical treatments for esophageal atresia,
700:00:18,585 --> 00:00:22,055but in this episode, we're going to tell you all about one of the newest options
800:00:22,322 --> 00:00:23,790magnet therapy.
900:00:23,790 --> 00:00:26,593I'm Rod Gerardo and I'm Ellen Enisco.
1000:00:26,726 --> 00:00:29,729We are research residents at Cincinnati Children's Hospital,
1100:00:29,996 --> 00:00:33,867and this is the Stay Current in Pediatric Surgery podcast.
1200:00:34,234 --> 00:00:35,068First, Dr.
1300:00:35,068 --> 00:00:38,571Bethany Slater from the University of Chicago, Comer Children's Hospital
1400:00:38,571 --> 00:00:41,741Department of Pediatric Surgery shares her case.
1500:00:45,412 --> 00:00:45,912Three month
1600:00:45,912 --> 00:00:49,849old male who has a history of a cardiac anomaly with a type
1700:00:49,849 --> 00:00:53,653A esophageal atresia or a pure esophageal atresia
1800:00:54,220 --> 00:00:56,956who had a gastrostomy place after birth
1900:00:57,023 --> 00:01:00,293and then had a gap study at again about three months of age,
2000:01:00,593 --> 00:01:04,831demonstrating a three centimeter gap between the proximal and distal esophagus.
2100:01:04,831 --> 00:01:07,200What will be the next step for an operative plan.
2200:01:07,600 --> 00:01:10,403So I think, you know, the question is what would
2300:01:10,403 --> 00:01:13,306people use as a criteria to say it's time to go back?
2400:01:13,406 --> 00:01:15,341Here's what I would consider at this point.
2500:01:15,341 --> 00:01:18,845I would try to go in and do it surgically if I go in to try to do it
2600:01:19,012 --> 00:01:22,215and get the two ends together after the section, proximaly and distally
2700:01:22,215 --> 00:01:23,883and I could not get them together.
2800:01:23,883 --> 00:01:24,651Then at that point
2900:01:24,651 --> 00:01:28,588I would do an internal lengthening procedure like the Vand Der Zee procedure.
3000:01:28,788 --> 00:01:30,490That's Dr. Todd Ponsky.
3100:01:30,490 --> 00:01:33,660He's a pediatric surgeon at Cincinnati Children's Hospital Medical Center.
3200:01:33,726 --> 00:01:35,161You don't lose anything
3300:01:35,161 --> 00:01:39,132by trying to go in and do the dissection to see if you can get them together.
3400:01:39,299 --> 00:01:40,066That's fair.
3500:01:40,066 --> 00:01:42,1023 centimeters is overcomable
3600:01:42,102 --> 00:01:45,338so I would try that thorascopically get those two ends together.
3700:01:45,338 --> 00:01:46,806And if you needed to do something different
3800:01:46,806 --> 00:01:48,341in the middle of the case, you could do that.
3900:01:48,341 --> 00:01:50,443That's Dr. Mack Harmon.
4000:01:50,443 --> 00:01:54,747He's the chief of pediatric surgery at Oshea Children's Hospital in Buffalo.
4100:01:54,848 --> 00:01:58,384Magnets have actually been used for many years for esophageal atresia.
4200:01:58,651 --> 00:02:03,389However, it can be used as a non-surgical alternative for esophageal and estimates,
4300:02:03,423 --> 00:02:07,160and they're able to promote lengthening and approximation of the proximal distal
4400:02:07,160 --> 00:02:08,495end of the esophagus.
4500:02:08,495 --> 00:02:13,099And then it uses compression and acidosis to create continuity of the esophagus,
4600:02:13,099 --> 00:02:14,834and there's an FDA approved,
4700:02:14,834 --> 00:02:17,604commercially available device called the Flourish Device.
4800:02:17,904 --> 00:02:20,273It's a catheter based magnet system.
4900:02:20,373 --> 00:02:22,442How does the flourish device work?
5000:02:22,442 --> 00:02:25,545Magnets are placed in the proximal and distal ends of the esophagus.
5100:02:26,079 --> 00:02:28,748They attract one another and cause the esophagus to lengthen.
5200:02:29,015 --> 00:02:30,950Then, once the magnets are nearly together,
5300:02:30,950 --> 00:02:32,652compression and estimate this happens
5400:02:32,652 --> 00:02:35,388as a result of ischemia in the tissue at the two ends.
5500:02:35,688 --> 00:02:36,189I see.
5600:02:36,189 --> 00:02:38,291So that's how the in astronauts this is created.
5700:02:38,825 --> 00:02:41,261Wow. OK, so what does this thing look like?
5800:02:41,261 --> 00:02:44,631It has both the esophageal and gastric catheters
5900:02:44,731 --> 00:02:47,700that have inner bullet sheet magnets on each end.
6000:02:47,834 --> 00:02:52,805Also, an important note it does taper down to a ten French coupling surface.
6100:02:52,805 --> 00:02:57,177Proximal catheter does have a suction port so that can be used
6200:02:57,177 --> 00:03:00,180to suction saliva from the patient while it's being used,
6300:03:00,180 --> 00:03:03,983and the gastric port has a portion for feeds as well.
6400:03:04,017 --> 00:03:08,788What about eligibility, both for the study and for the placement of these magnets?
6500:03:08,821 --> 00:03:11,191Dr Slater, could you explain a little bit, please?
6600:03:11,491 --> 00:03:15,128So there needs to be a gap length of less than four centimeters.
6700:03:15,295 --> 00:03:17,230Lengths are greater than that.
6800:03:17,230 --> 00:03:20,200The magnets will not attract one another, so they can't be used.
6900:03:20,733 --> 00:03:24,704And an important thing here, there should be no fistula
7000:03:25,004 --> 00:03:28,575or if there is a fistula, you have to repair that first.
7100:03:28,908 --> 00:03:29,709And the patients
7200:03:29,709 --> 00:03:33,746do require a gastrostomy that can accommodate an 18 French catheter
7300:03:33,880 --> 00:03:38,351because that is the diameter of the gastric portion of the catheter.
7400:03:38,484 --> 00:03:38,985Gotcha.
7500:03:38,985 --> 00:03:43,122When we start learning these things that the second phase is OK, great,
7600:03:43,122 --> 00:03:44,157we can do it.
7700:03:44,157 --> 00:03:45,959second half is when do we do it?
7800:03:45,959 --> 00:03:49,429So it's not to replace esophageal treasurer repair.
7900:03:49,429 --> 00:03:52,332It's that now you have another tool in your armamentarium,
8000:03:52,332 --> 00:03:55,068particularly patients who have cardiac disease
8100:03:55,068 --> 00:03:59,172or had previous operations that might make them less of a candidate
8200:03:59,572 --> 00:04:03,910for a re operative surgery or an increased risk of the anesthetic.
8300:04:03,910 --> 00:04:07,280For whatever reason, this patient then falls into this for multiple reasons.
8400:04:07,280 --> 00:04:12,085That right, because the gap is is three centimeters, so the size criteria fits.
8500:04:12,252 --> 00:04:14,821This patient doesn't have a fistula, so that's great.
8600:04:14,821 --> 00:04:18,491They have the gastrostomy tract that was made shortly after birth.
8700:04:18,758 --> 00:04:21,394And then on top of that, this patient has a cardiac anomaly.
8800:04:21,394 --> 00:04:24,864So then the concern for high risk for the operation,
8900:04:24,864 --> 00:04:27,133then that kind of goes out the window when you look towards a magnet
9000:04:27,133 --> 00:04:29,502therapy approach is that the Rakhis Coppock approach
9100:04:29,502 --> 00:04:31,237or other surgical management?
9200:04:31,237 --> 00:04:35,308Of course, any device, it's important to note the indications of use and proceed
9300:04:35,308 --> 00:04:36,276with caution,
9400:04:36,276 --> 00:04:39,579keeping in mind the recommendations from the device company
9500:04:40,113 --> 00:04:43,883that will create a safer option for surgeons, as well as for their patients.
9600:04:44,284 --> 00:04:45,551Just to say in the beginning,
9700:04:45,551 --> 00:04:48,688I'm not convinced that there's not a role for magnets in this,
9800:04:48,688 --> 00:04:52,392but I thought it important to people be aware of of some of the issues.
9900:04:52,458 --> 00:04:54,460That's Dr. Steven Rothenberg.
10000:04:54,761 --> 00:04:59,332He's the chief of pediatric surgery at Rocky Mountain Hospital for Children.
10100:04:59,799 --> 00:05:04,871So this was a full term male who was born with pure esophageal atresia.
10200:05:04,904 --> 00:05:08,141He had a gastrostomy placed at birth about six weeks of age.
10300:05:08,274 --> 00:05:09,309They had a gap study
10400:05:09,309 --> 00:05:13,179that showed a three and a half side a meter gap a little over six weeks later.
10500:05:13,179 --> 00:05:14,614So three months of age
10600:05:14,614 --> 00:05:19,152patient at another gap study, which showed a gap of 2.6 centimeters.
10700:05:19,519 --> 00:05:22,655At this point, the decision was made to use the first device
10800:05:23,089 --> 00:05:25,958after placing the magnets they had to reposition them once.
10900:05:26,526 --> 00:05:29,562four days later, the patient had an acute decompensation.
11000:05:29,862 --> 00:05:33,733He was transferred to another local children's center,
11100:05:33,833 --> 00:05:36,703and they eventually ended up deciding to come to our institution.
11200:05:36,903 --> 00:05:40,239And when I did it, and that's our program in the upper pouch, it showed that
11300:05:40,239 --> 00:05:43,576there was an upper pouch fistula, which had not previously.
11400:05:43,676 --> 00:05:45,078And diagnosed.
11500:05:45,078 --> 00:05:49,015Now the question is whether it's a true fistula or traumatic fistula.
11600:05:49,182 --> 00:05:52,552And when I scope the patient, it was a true upper palate fistula.
11700:05:52,652 --> 00:05:55,588As Dr Slater said before, one of the contraindications
11800:05:55,588 --> 00:05:58,524for using the Fleurs device is the presence of a fistula.
11900:05:58,825 --> 00:06:03,529So now we know there's an upper pouch, fistula and a five centimeter gap.
12000:06:03,730 --> 00:06:05,832So what do we do next?
12100:06:06,032 --> 00:06:11,704Normally I would fix that up for pouch fistula through Dorcas could be, we lie,
12200:06:11,738 --> 00:06:14,841get all our upper pouches, fistulas and take this to us now.
12300:06:14,841 --> 00:06:17,443Dorcas got the clip because I think the view is excellent.
12400:06:17,443 --> 00:06:20,980We get good control, but because this child's chest was a mess,
12500:06:20,980 --> 00:06:24,183I did a dissection, went in and located that fistula.
12600:06:24,250 --> 00:06:29,522I also found a traumatic fistula, which I like, gated with five millimeter stapler.
12700:06:29,689 --> 00:06:34,794I dissected out its lower pouch, which there was still a persistent fistula.
12800:06:34,794 --> 00:06:35,561We divided,
12900:06:35,561 --> 00:06:37,463and then I was actually able to mobilize
13000:06:37,463 --> 00:06:39,465the two ends together and get them together.
13100:06:39,465 --> 00:06:42,168I think it was quite lucky. So what about after surgery?
13200:06:42,168 --> 00:06:43,970What does his recovery look like?
13300:06:43,970 --> 00:06:45,204He's done quite well.
13400:06:45,204 --> 00:06:46,239He does have a stricture,
13500:06:46,239 --> 00:06:50,009which is we're dilating about once a month and he's now learning to eat.
13600:06:50,476 --> 00:06:53,880I have to wonder, were there any other options for Dr.
13700:06:53,880 --> 00:06:54,714Rothenberg?
13800:06:54,714 --> 00:06:58,384So he was in the hospital the first almost six months of his life.
13900:06:58,584 --> 00:07:02,755And my basic common here is this child had a gap at one point of two
14000:07:02,755 --> 00:07:06,893and a half centimeters that I think whether you did it sarcastically or open
14100:07:06,893 --> 00:07:11,197could have fixed by classification of the International Esophageal Atresia Group,
14200:07:11,564 --> 00:07:15,435you have to have a gap of at least four centimeters to be considered long gap.
14300:07:15,601 --> 00:07:18,304The indications for the magnet is you have to have a gap of less
14400:07:18,304 --> 00:07:19,338than four sodomy
14500:07:19,338 --> 00:07:23,109and you're getting an incredibly high stricture rate and multiple strictures.
14600:07:23,109 --> 00:07:25,111And so I have some concerns.
14700:07:25,111 --> 00:07:28,881I'm not completely against magnets, but I would argue that a patient
14800:07:28,881 --> 00:07:31,884who's got less than a four sided meter gap should be amenable
14900:07:31,884 --> 00:07:35,288to a primary and asked about this, and we would of course, do it.
15000:07:35,288 --> 00:07:36,222Dark-Sky quickly.
15100:07:36,222 --> 00:07:41,194Yeah, the reason I think it was so great that Steve presented this, especially me.
15200:07:41,194 --> 00:07:44,530I'm very excited about new technology and I get all excited
15300:07:44,530 --> 00:07:46,132and I tell everybody about it.
15400:07:46,132 --> 00:07:51,137But it's nice to have some cautionary tales as well as new technology comes out.
15500:07:51,404 --> 00:07:54,640Additionally, magnets have been used sometimes for a staged
15600:07:54,640 --> 00:07:57,510repair rather than using internal traction sutures.
15700:07:57,610 --> 00:08:02,281There is also a possibility of trying to get the two ends together
15800:08:02,281 --> 00:08:07,353closer surgically and then using a magnet just for the anatomy of this portion
15900:08:07,353 --> 00:08:08,354as a possibility.
16000:08:08,354 --> 00:08:11,624Magnets are a great innovation, but they're no joke
16100:08:11,624 --> 00:08:12,892and they need to be taken seriously.
16200:08:12,892 --> 00:08:15,761So just because you have experience with the soft tissue of treasure
16300:08:16,062 --> 00:08:18,297doesn't mean you have experience with using the magnets.
16400:08:18,364 --> 00:08:23,202What Rothenburg was suggesting is that if you're at an institution where you have
16500:08:23,202 --> 00:08:27,273what looks like a relatively long gap that you want to get together
16600:08:27,640 --> 00:08:32,411and you personally don't know if you would be able to get it together
16700:08:32,411 --> 00:08:37,483in your experience, in your hands, the next step is not to do magnets.
16800:08:37,617 --> 00:08:38,718The next step would be
16900:08:38,718 --> 00:08:42,889to send that to a center that could do it open talk escapist, whatever.
17000:08:42,922 --> 00:08:46,359It's not meant to make esophageal atresia repair
17100:08:46,359 --> 00:08:49,996more accessible to everyone that begins, right?
17200:08:50,062 --> 00:08:51,397I love that statement.
17300:08:51,397 --> 00:08:54,734If you don't feel like you can get it together through a surgical approach
17400:08:55,067 --> 00:08:58,905and you have no experience using magnets, that should not be your next step.
17500:08:58,938 --> 00:09:01,507That's like the moral story of this case.
17600:09:01,507 --> 00:09:03,442I think there are emerging new technologies
17700:09:03,442 --> 00:09:05,978that are very exciting, and I think they hold a lot of promise
17800:09:05,978 --> 00:09:09,549because the root of this technology is trying to solve is
17900:09:09,749 --> 00:09:12,652there are two pieces of an organ that need to be connected,
18000:09:12,985 --> 00:09:17,890and they're not here as a less invasive way to connect them.
18100:09:17,890 --> 00:09:22,562That is a very basic, rudimentary surgical concept.
18200:09:22,662 --> 00:09:27,199I think us, oftentimes when we see these new techniques, it seems almost easier
18300:09:27,266 --> 00:09:30,469than the traditional operation because it looks like,
18400:09:30,469 --> 00:09:32,171Oh, you put magnets in and you're done.
18500:09:32,171 --> 00:09:36,742And sometimes these easy solutions are actually not easier, right?
18600:09:36,909 --> 00:09:37,476Exactly.
18700:09:37,476 --> 00:09:39,412So we just have to remember to be conscious
18800:09:39,412 --> 00:09:41,948and thinking about kind of the decision pathway.
18900:09:41,981 --> 00:09:46,986And if you're not comfortable managing the esophageal atresia yourself
19000:09:47,286 --> 00:09:51,324sarcastically wrote an open procedure, then think about consulting
19100:09:51,324 --> 00:09:54,193with a center who is more experienced.
19200:09:54,527 --> 00:09:58,564So there you have it our 2021 update course
19300:09:58,564 --> 00:10:01,901session on magnet therapy for esophageal atresia.
19400:10:01,901 --> 00:10:04,370Now, if you loved this episode,
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20000:10:20,319 --> 00:10:23,689But until next time, I'm Todd, I'm Rod and I'm Ellen, and
20100:10:23,823 --> 00:10:25,725remember knowledge should be free.
